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All Western European countries have seen marked improvements in life expectancy over the past few decades, however, these countries also experience varying levels of in-country health inequalities. Indeed excess mortality and reductions in healthy life years are closely correlated to regional deprivation. Conventional explanations for health inequalities, such as lack of access to medical care and unhealthy lifestyles, provide only part of the explanation; the more intransigent causes include access to and opportunities in education, employment, housing, public transport and welfare services.

Breaking the dependency cycleThe 1946 Constitution of the WHO and subsequently the 1966 UN International Covenant on Economic, Social and Cultural Rights, stated that the fundamental right of every human being is to enjoy the highest attainable standard of physical and mental health. , Throughout my career as a doctor I have been guided by these powerful words, moreover, I chose to become a doctor to help my patients and their families to obtain the best outcomes within my power to deliver. However, I have seen first-hand how the conditions in which people are born, grow up, live, work and grow old, known as the social determinants of health (SDoH), are closely linked to achieving the above, and other human rights, such as the right to food, housing, just and favourable conditions of work, education, security, non-discrimination, access to information and social participation.

During my years of medical practice, my colleagues and I saw how the many interrelated SDoH result in avoidable ill-health and lower life expectancies for families experiencing socioeconomic deprivation. We experienced that achieving the rights outlined by the WHO and the UN often seemed out of reach, for certain families, and for the health and social care professionals involved in their care. Quite often, we would have the nagging thought of foreboding, observing that children growing up in families experiencing higher levels of social deprivation “didn’t really stand a chance”.

My interest in such issues led me to welcome the opportunity to lead the research for the above report and examine the impact of social deprivation through the lens of vulnerable families, some of the most disadvantaged groups in our societies. ‘Vulnerable’ or ‘troubled families’, are defined as those that are in contact with several departments of the local authority and are a growing concern to most societies. These families rarely succeed in breaking the negative spiral, which leads to persistent poverty, deprivation and transgenerational dependency on public support. Living in vulnerable families accentuates the risks of poor life outcomes for those most dependent on family structures, especially children and adolescents. Our research shows that children and young people who are known in the social services system from childhood are overrepresented later in life in the benefit system. They will also struggle to achieve their full potential with negative consequences for their life outcomes.

Most Western European countries have struggled to tackle the causes of health inequalities and the failure to improve the lives of vulnerable families is often rooted in a siloed and reactive approach, creating avoidable cost and social pressures on care systems and society.

My aim in working on this report, was to try and quantify the economic and social case for tackling the SDoH and their impact on health inequalities and identify examples of good practice. We reviewed and synthesised a large volume of research and analysed numerous national and international datasets for our report. We also drew on the experience of our colleagues across Europe.

The report illustrates how taking a life cycle approach to vulnerable families can improve targeting, prioritisation and impact of services at all stages of life. Some of our key findings, including some of the ‘not so fun’ facts of health inequality, are as follows:The report illustrates how taking a life cycle approach to vulnerable families can improve targeting, prioritisation and impact of services at all stages of life. Some of our key findings, including some of the ‘not so fun’ facts of health inequality, are as follows:

lack of access to medical care and unhealthy lifestyles only partially explain differences in health status as, at most, only 15-25 per cent of health outcomes are determined by healthcare, yet healthcare still receives one of the largest overall share of public expenditure

most major cities like London, Glasgow and New York, have an extremely wide social gradient with a life expectancy gap of around 20 years, running from the most affluent to the most deprived areas

in the EU avoidable health inequality contributes to 700,000 deaths, 33 million cases of ill health annually, cutting 1.4 per cent of European GDP off labour productivity and accounting for an estimated 20 per cent of European healthcare costs

education matters – for every extra year of education received by women, there is a seven to nine per cent reduction in mortality among their children under five, regardless of whether education enrolment increases from high levels (ten to eleven years) or low levels (two to three years). Furthermore, Europeans with the highest educational attainment can expect to live 5.6 years longer when compared to those with the lowest

the environment people live in shapes their behaviour; yet, the most deprived ten per cent of communities in England have five time less green space than the most affluent 20 per cent, reducing their likelihood of exercising but also negatively impacting their mental health

access to fast broadband and the internet at a household level is becoming an important social determinant of health, as most countries aim to implement technology-enabled care solutions to improve access to care and reduce costs; yet older people with the lowest income are over five times less likely to be using the internet, than those with the highest monthly incomes.

Importantly our research, and that of others, shows that giving every child the best possible start in life is likely to deliver the best societal and overall health benefits. However, breaking the cycle of dependency for future generations also requires improvements in the living and working conditions of adult and elderly family members.

Our report identifies numerous evidence-based case examples from countries across Europe, where policymakers, public service providers, agencies and other stakeholders are beginning to work across institutional and professional boundaries to improve life chances and achieve better health and wellbeing outcomes. These case examples highlight that focused, sustainable change is achievable, and scalable if stakeholders are prepared to learn from what works. A data- and evidence driven understanding of the interacting determinants of health and social functioning therefore needs to be translated into policy interventions that are co-created, empower the citizen, and meet local needs.

These and the other findings in our report have helped me understand more clearly the challenges I faced working in healthcare and the importance of tackling both health and social inequalities, especially for vulnerable families. However it also made me realise that if the most disadvantaged members of society can be helped to improve their health outcomes, then the solutions that work should also help other disadvantaged groups.

By sharing the insights in our report we hope to spark debate, stimulate learning from the good practice examples and encourage actions that help reduce overall health inequalities in all countries.

Dr Mina Hinsch, MD - Research Manager, UK Centre for Health Solutions

Mina is a research manager at Deloitte UK’s Centre for Health Solutions. The Centre is the research arm of Deloitte LLP’s healthcare and life sciences practices. She has wide experience relevant to current issues of public and health policy debates regarding financing of healthcare and scientific research as much as regulation of medicines and services. Her previous years of clinical work included teaching and research in psychiatry, neurology and medical ethics. Mina is fluent in English, German and Portuguese and proficient in French.

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